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Haematology > Obstetric Haematology > Flashcards

Obstetric Haematology Flashcards

1
Q

During normal pregnancy…

  • Less iron required
  • There is an increase in haemoglobin concentration
  • The platelet count falls
  • The neutrophil count falls
A

The platelet count falls

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2
Q

How does the FBC change in pregnancy?

A
  • Mild anaemia
    • –Red cell mass rises (120 -130%)
    • –Plasma volume rises (150%) = net dilution
  • Macrocytosis–Normal–Folate or B12 deficiency
  • Neutrophilia
  • Thrombocytopenia
    • –increased platelet size
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3
Q

What are the demands of pregnancy?

A
  • Iron requirement
  • Folate requirement
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4
Q

Describe iron requirement.

A

–300mg for fetus

–500mg for maternal increased red cell mass

–RDA 30mg;

– Increase in daily iron absorption:1-2mg to 6mg

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5
Q

Describe folate requirement.

A

–Growth and cell division

–Approx additional 200mcg/day required

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6
Q

What is the consequence of iron deficiency?

A

may cause IUGR, prematurity, postpartum haemorrhage

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7
Q

Describe iron homeostasis.

A
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8
Q

How does the iron cycle differ in pregnancy?

A
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9
Q

What is the recommendation of iron and folate in pregnancy?

A

nFolic acid

–Advise reduces risk of neural tube defects

–Supplement before conception and for ≥ 12 weeks gestation

–Dose 400μg / day

Iron

–No routine supplementation in UK

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10
Q

What is the content of elemental iron?

A

Pregaday 100mg,

Pregnacare 17mg,

Ferrous Sulphate 65mg (in 200mg dose) ,

Continue for 3 months following correction of Hb

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11
Q

Define anaemia in pregnancy-

A

Definition

–Hb < 110 g/l 1st trimester

–Hb < 105 g/l 2nd and 3rd trimester

–Hb < 100 g/l postpartum

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12
Q

How do we diagnose iron deficiency anaemia?

A
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13
Q

How does platelet count change in pregnancy?

A

Falls in pregnancy

Non-pregnant: 225-249 x 109/L

Pregnant: 175-199 x 109/L

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14
Q

How does platelet count change in pregnancy?

A

Falls in pregnancy

Non-pregnant: 225-249 x 109/L

Pregnant: 175-199 x 109/L

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15
Q

What are the causes of thrombocytopenia in pregnancy?

A
  • Physiological:
    • –‘gestational’/incidental thrombocytopenia
  • Pre-eclampsia
  • Immune thrombocytopenia (ITP)
  • Microangiopathic syndromes
  • All other causes: bone marrow failure, leukaemia, hypersplenism, DIC etc.
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16
Q

If plt < 150 x 109/L, < 100 x 109/L, < 70 x 109/L - what is the most likely cause?

A
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17
Q

What is gestational thrombocytopenia? What is the mechanism? What number is sufficient for delivery? Who is affected? How does it resolve?

A
  • Physiological decrease in platelet count ~ 10%
  • >50x109/l sufficient for delivery (>70 for epidural)
  • Mechanism poorly defined– Dilution + increased consumption
  • Baby not affected
  • Platelet count rises D2 – 5 post delivery
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18
Q

How many women with pre-eclampsia get thrombocytopenia? Why does it occur= What is associated with? How does it resolve?

A
  • 50% get thrombocytopenia
    • Proportionate to severity
  • Probably due to increased activation and consumption
  • Associated with coagulation activation–(incipient DIC – normal PT, APTT)
  • Usually remits following delivery
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19
Q

How common is ITP in pregnancy? How is it managed? What are the effects of it?

A
  • 5% of thrombocytopenia in pregnancy
    • TP may precede pregnancy
    • Early onset
  • Treatment options (for bleeding or delivery)
    • IV immunoglobulin–Steroids etc.
  • Baby may be affected
    • Unpredictable (platelets <20 in 5%)
    • Check cord blood and then daily
    • May fall for 5 days after delivery
    • Bleeding in 25% of severely affected (IVIG if low)
    • Usually normal delivery
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20
Q

What happens in microangiopathic syndromes? What are the consequences?

A

–Deposition of platelets in small blood vessels

–Thrombocytopenia

–Fragmentation and destruction of rbc within vasculature

Organ damage (kidney, CNS, placenta

21
Q

What are the MAHA syndromes?

A

Delivery does not alter course of TTP or HUS

22
Q

What are the MAHA syndromes?

A

Delivery does not alter course of TTP or HUS

23
Q

Coagulation changes in pregnancy…

  • Increase the likelihood of bleeding
  • Result in a hyperfibrinolytic state
  • Are mediated by betaHCG
  • Result in a leading cause of maternal mortality
A

Result in a leading cause of maternal mortality

24
Q

VTE in pregnancy

A

B

25
Q

What are the causes of mortality in pregnancy?

A
  • VTE - most common
26
Q

Summarise the major changes in pregnancy.

A
27
Q

What are the net changes in coagulation in pregnancy?

A
28
Q

What are the RFs of PEs in pregnancy?

A
  • Post-partum followed by 1st trimester
  • BMI > 25
  • Age > 40
29
Q

What us the incidence of thrombosis in pregnancy?

A
  • 1 per 1000 <35 years
  • 2 per 1000 >35 years
  • Relative risk approx. x10
  • One third are post partum (only 6 weeks)
  • Doppler and VQ are safe to perform in pregnancy
  • D-dimer often elevated in pregnancy–Not useful for exclusion of thrombosis
30
Q

What improvements have been made in order to prevent maternal deaths?

A

Improved assessment of risk

Public health education: identify women at risk because of their weight, family history or past history to seek advice before becoming pregnant. RCOG guidelines 2004

Increased recognition of symptoms in early pregnancy - chest pain / SOB / leg pain

Diagnosis - Increased awareness that diagnostic tests (VQ / CXR / Venogram/ CTPA) are safe

Treatment

  • Wider use of thromboprophylaxis
  • Therapy should be given pending the results of further testing
31
Q

What is the prevention of thromboembolic disease in pregnancy?

A
  • Women with risk factors should receive prophylactic heparin +TED stockings
    • –Either throughout pregnancy
    • –Or in peri-post- partum period
    • –Highest risk get adjusted dose LMWH heparin
  • Mobilise early
  • Maintain hydration
32
Q

How do we treat thromboembolic disease in pregnancy?

A
  • Management
    • LMWH as for non-pregnant
      • Does not cross placenta
      • RCOG recommend once or twice daily
    • Do not convert to warfarin (crosses placenta)
    • After 1st trimester monitor anti Xa
      • 4 hour post 0.5-1.0u/ml
  • Stop for labour or planned delivery, esp. for epidural
    • Epidural: wait 24 hours after treatment dose, 12 hours after prophylactic dose
33
Q

What is chrondrodysplasia punctata?

A
34
Q

What is the consequence of anti phospholipid syndrome?

A
35
Q

Why does fatal bleeding occur? What do we do?

A
36
Q

How do we determine PPH? How common is >1L loss? How company require transfusions?

A
  • Post Partum Haemorrhage (PPH) : > 500 mL blood loss
  • 5% of pregnancies have blood loss >1 litre at delivery.
  • Requiring transfusion post partum
  • –1% after vaginal delivery
  • –1-7% after C-Section
37
Q

What is the mechanism of PPH?

A
  • major factors are
    • uterine atony
    • trauma
  • haematological factors minor except
    • dilutional coagulopathy after resuscitation
    • DIC in abruption, amniotic fluid embolism etc.
38
Q

What is DIC precipitated by in pregnancy?

A
  • Coagulation changes in pregnancy predispose to DIC.
  • Decompensation precipitated by:
    • Amniotic fluid embolism
    • Abruptio placentae
    • Retained dead fetus
    • Preeclampsia (severe)
    • Sepsis
39
Q

What is amniotic fluid embolism? How common is it? How does it present? What is the mortality associated with it? When does it occur?

A
40
Q

What are the aims of haemoglobinopathy screening?

A
41
Q

How do we detect haemoglobinopathies?

A
42
Q

How do we counsel about haemoglobinopathies?

A
43
Q

How do we differentiate between iron deficiency anaemia and thalassaemia trait?

A
44
Q
A

D

45
Q
A

B

46
Q
A

B

47
Q
A

HELLP syndrome

48
Q
A

Iron deficiency

Haematology (16 decks)

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